Andrew Rees
9 Jan 2024 · Coroner Myfanwy Buckeridge · Avon
The coroner's concerns
1. broken rescue chain on marina wall
“in the vicinity of where the deceased was retrieved from the water, the rescue chain on the wall of the marina was broken and that the system of visual inspection in place by Boatfolk Marinas Ltd had not identified this”
2. lack of formal assessment of change of use
“a significant change of use but no formal assessment or measure of whether a change of use (e.g. increase in amount or type of footfall/increased cyclists etc.) had taken place was apparent”